First Responders to Orthopaedic Emergencies

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Ronald Stokes
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First Responders to Orthopaedic Emergencies Tom McPartland MD FABOS, FAAP Assistant Clinical

Definitions of Different Types of Injuries Discuss Assessment of Injuries Discuss Decisions for

happen 80% of school kids visit the nurse Sometimes they happened at home or on the way to school

1 First Responders to Orthopaedic Emergencies Tom McPartland MD FABOS, FAAP Assistant Clinical Professor Rutgers-RWJMS October 17,2018 Goals Review Epidemiology of School Injuries Review Definitions of Different Types of Injuries Discuss Assessment of Injuries Discuss Decisions for Treatment and Triage Understand what happens after they leave your office Injuries are going to happen 80% of school kids visit the nurse Sometimes they happened at home or on the way to school and you are the one fixing them Always be on the lookout for signs of child abuse (Non accidental trauma NAT) 1

Kids come in varying levels of toughness There are no frequent flyer miles

Orthopedic Injuries Musculoskeletal Injuries Athletics Playground Slip and

2 million school injuries per year 1 Injury types 2 Fractures 30% Lacerations

2 Kids come in varying levels of toughness There are no frequent flyer miles When are they really hurt? Orthopedic Injuries Musculoskeletal Injuries Athletics Playground Slip and Fall Cuts and Scrapes Altercations Epidemiology 3.2 million school injuries per year 1 Injury types 2 Fractures 30% Lacerations 25% Sprains 12% Bumps and bruises 11% Concussion 4% (LOC <1%) 1 Am J of Public Health 1998 Mar;88(3): J of School Health December 1999 Vol 69 No

3 Epidemiology High school gym (1.5/100) Middle school athletic field (4.3/100) Elementary school playground (6.1/100) Middle School > Elementary School> High School Grade school K-6 Recess 66% Gym 11% Location Playground 68% Grade % occurred in gym 35% occurred during sports Am J Prev Med May-Jun;8(3): J of School Health December 1999 Vol 69 No Epidemiology Overall incidence 16 per 1000 boys 11 per 1000 girls Causes 1) Collision 2) Trip/Fall 85% saw physician EMS called 2.2% Hospitalized 1.4% J of School Health December 1999 Vol 69 No Definitions Soft Tissue Injuries Abrasions Practically everyday at every grade level Lacerations Avulsion Puncture Scalp and Nail Injuries 3

4 Soft Tissue Injuries Punctures Sharp deep penetration Can leave a foreign body behind May not bleed very much Avulsion injuries Loss of tissue 4

frequent mechanism Knee Sprains Mechanism Lateral blow with fixed foot (MCL) Twisting Hyperextension

5 Definitions Sprains and Strains Sprains injuries to ligaments Strains - injuries to muscles and tendons Ankle Sprains Most common cause of lower extremity pain 25,000 ankle sprains per day Inversion most frequent mechanism Knee Sprains Mechanism Lateral blow with fixed foot (MCL) Twisting Hyperextension Sprain may involve named ligaments and joint capsule Traumatic effusion usually indicative of a more significant problem 5

$fractures Wrist Finger Collarbone$ Displaced Dislocations Special

6 Fractures Fractures occur more commonly in children because their bones are smaller (bone strength related to radius 3 ) Most common fractures Wrist Finger Collarbone Nondisplaced vs. Displaced Dislocations Special Tissues and Situations Nail Nail may fall off no need to find or preserve nail Control Bleeding Scalp May bleed a lot!!! wound gaps and very vascular area Amputation of part Place part in saline in ice bag (not in direct contact with ice) 6

Bites Animal or human bites are very dirty wounds Hands and fingers most commonly affected areas Wild animal bites or scratches can be complex lacerations Compress to control bleeding Evaluate in ER

7 Bites Animal or human bites are very dirty wounds Hands and fingers most commonly affected areas Wild animal bites or scratches can be complex lacerations Compress to control bleeding Evaluate in ER Will need Anitbiotics and tetanus coverage Fight bite Assessment History from patient and witnesses Get a localization complaint (#1, #2, #3) Identify likely sites of injury based on your localization complaint and physical exam Inspection Palpation Functional Testing Make a diagnosis and start treating First Aid-Treatment Priorities Assess for any life threatening injuries Airway, Breathing, Circulation Assess for all injuries > treat in order of severity Reassure patient Stop bleeding Stabilize injuries Clean contamination if possible Dress wounds Immobilize injuries Relieve Pain Decide next steps 7

8 Bleeding Pressure works Hold for 5-10 minutes Avg bleeding time is 4 1/2 minutes Pressure points Tourniquet always possible if needed Initial Treatment Splints 8

9 Finger Splints Tools of the Trade Displaced Fractures and Dislocations Splint in a position of comfort Ice Hospital If fracture has a skin opening, dress with gauze 9

crutches, tweezers, Splint materials Fingers Moldable splints When to Treat or When to Transfer

10 Stock your Office Different needs for different practices Budget, Space available, Scope of Practice Saline, gauze, roller gauze, finger splints, tape, ace bandages,folding wheelchair, crutches, tweezers, Splint materials Fingers Moldable splints When to Treat or When to Transfer Need a full assessment Gauge child s response to your treatment No substitute for the My Kid test 10

$Absolute indications to Call EMS displaced fracture or dislocated joint Uncontrolled bleeding Any loss of neurologic function loss of consciousness for any significant period of$ office??? So What Happens at the ER or Docs Office?

office??? So What Happens at the ER or Docs Office?

11 Absolute indications to Call EMS displaced fracture or dislocated joint Uncontrolled bleeding Any loss of neurologic function loss of consciousness for any significant period of time When to call a parent Call parent and send to ED Soft tissue avulsion or laceration >2cm Limited motion or cannot bear weight on lower extremity(ies) ER or pediatrician s office??? So What Happens at the ER or Docs Office? Full assessment Identify and relate injuries Determine infection risk administer antibiotics if indicated Treat Pain Address Injury Temporary stabilization Splints Definitive Treatment Repair soft tissues Reduce Fractures/Dislocations Splints/casts Surgery Recovery and Rehabilitation Return to Activity 11

Soft Tissue Injuries Abrasions dressed 3-7 days recovery Punctures Make sure no retained

weeks Return to activity when skin tension adequate Suture Repair Cleansing of deep tissues

Will usually remove Splinters of material can usually be removed with topical anesthetic and

12 Soft Tissue Injuries Abrasions dressed 3-7 days recovery Punctures Make sure no retained foreign body Tetanus prophylaxis Lacerations Suture repair Antibiotics Sutures removed 1-2 weeks Return to activity when skin tension adequate Suture Repair Cleansing of deep tissues Antibiotic and tetanus coverage Layered rapair Absorbable vs Nonabsorbable Foreign Bodies Will usually remove Splinters of material can usually be removed with topical anesthetic and a needle or forceps Minor surgical procedure Retained foreign bodies can be walled off by the body. 12

Amputations/Avulsions Fracture Treatment Fractures require stability and

Complete/Incomplete Displaced/Nondisplaced Diaphyseal/Metaphyseal

$Type of bone Relative stability of the fracture General Health of the$

13 Amputations/Avulsions Fracture Treatment Fractures require stability and good blood flow to heal Fractures comes in lots of types Complete/Incomplete Displaced/Nondisplaced Diaphyseal/Metaphyseal Simple/Comminuted Closed/Open Conditions affecting rate of healing Age Location in Bone Factors affecting bone healing Age Location in Bone Type of bone Relative stability of the fracture General Health of the Patient Weightbearing bone? 13

14 Fracture Reduction Fracture Reduction 14

15 Cast Materials Proper Molding 15

$fractures that do not have$

16 Proper Molding Not All Fracture Need Casts Surgery Performed for fractures that do not have inherent stability Usually elbows and femurs 16

17 Supracondylar Humerus Fracture Flexible Intramedullary nailing 17

18 Femoral Bridge Plating How do we consider rehabilitation Restrictions in School Gym We want them back in gym!! We will clear them when it is appropriate Crutches/Walkers/Wheelchairs Each school has different abilities to accommodate Safety is the most important factor Give kids more time to change class/go to lockers Give them a buddy or aid Elevators Easy transition to busing 18

19 Return to Activity After Injury Principles Safety of patient Safety of other children playing with them Soft tissue injuries 2-6 weeks Fractures 6-16 weeks depending on location Sports injuries with ligament reconstruction 4-6 months Ground Rules in School Playground Age appropriate use of equipment Monitor unsafe usage Gym Focus on warm-up May incorporate skills of balance and proprioception, especially in middle school Avoid collisions when possible No running in the hallways 19

20 THANK YOU FOR ALL THAT YOU DO FOR OUR KIDS 20

Surgical Care at the District Hospital. EMERGENCY & ESSENTIAL SURGICAL CARE

Surgical Care at the District Hospital 1 18 Orthopedic Trauma Key Points 2 18.1 Upper Extremity Injuries Clavicle Fractures Diagnose fractures from the history and by physical examination Treat with a